HEENT Physical Assessment Assignment Results | Completed
Advanced Health Assessment - Chamberlain, NR509
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Your Results Turn In Lab Pass
Overview
Subjective Data Collection: 25 of 28 (89.3%)
Transcript
Subjective Data Collection Hover To Reveal...
Indicates an item that you found.
Hover over the Patient Data items
Objective Data Collection Indicates an item that is available to be
below to reveal important information,
found.
including Pro Tips and Example
Education & Empathy
Questions.
Documentation
Lifespan Category Scored Items Patient Data
Review Questions Not Scored
Experts selected these topics as essential
Self-Reflection A combination of open and closed questions
components of a strong, thorough interview
will yield better patient data. The following
with this patient.
details are facts of the patient's case.
Chief Complaint
Established chief complaint Reports sore throat
Reports itchy throat
Reports itchy eyes
Reports runny nose
History of Present Illness
Asked about onset of symptoms Reports sore throat began "about a week
ago"
Reports runny nose began "about a week
ago"
Reports itchy eyes began "about a week
ago"
Asked about aggravating factors for Reports throat pain is constant
throat symptoms
Reports throat pain is worse in the
morning
Reports some soreness with swallowing
Asked severity of throat discomfort Describes sore throat as mild to moderate
Asked about frequency and duration of Reports nose is runny "pretty much all
runny nose day"
Asked about character of nasal Denies itchy nose
symptoms
Denies sinus pain
Denies sinus pressure
Denies sneezing
Followed up about character of nasal Reports clear discharge
discharge
Reports thin discharge
Denies purulent discharge
Asked about eye symptoms Reports eye itching is constant
Reports eye redness
Asked related respiratory symptoms Reports breathing isn't affected
Denies cough
Denies chest tightness
Asked about related asthma symptoms Denies recent wheezing
Denies increase in recent asthma
symptoms
Asked about exposure to allergens Reports no exposure to cats
Reports no exposure to mold or mildew
Reports no exposure to dust
Reports no known exposure to irritants in
work environment
Reports changing bedding "once a week"
Asked about perceived cause of Describes symptoms as similar to
symptoms allergies
Reports that the symptoms don't seem
like a common cold
Describes similarity to her sister's hay
fever symptoms
Reports no history of cigarette smoking
Reports no recent exposure to
secondhand smoke
Medical History
Confirmed use of medications Confirmed medications from previous visit
(no new medications)
Followed up about inhaler use Uses an inhaler to treat asthma symptoms
Inhaler is Proventil
Last use of inhaler was last week
Reports typical inhaler use is 2 - 3 times a
week
Reports using 2 - 3 puffs of inhaler when
used
Prescribed dosage is 2 puffs
Followed up about medications and Reports no treatment for itchy eyes
relieving factors for nose and eye symptoms
Reports no treatment for nasal symptoms
Reports no antihistamine
Reports no decongestant
Followed up about medications and Reports lozenges as treatment
relieving factors for throat symptoms
Reports lozenges reduce symptoms
Reports ingesting lozenges every few
hours
Reports drinking water reduces symptoms
Confirmed allergies Reports known allergy to cats
Reports known allergy to dust
Reports no previous problems with
seasonal allergies
Review of Systems
Asked about general symptoms Denies recent or frequent illnesses
Denies chills
Denies fever
Reports low energy level
Denies nausea or vomiting
Asked about review of systems for head Reports occasional headaches
Denies current headache
Denies history of head injury
Denies lightheadedness
Followed up on headaches Headaches occur once a week
Headaches last "a few hours"
Describes headaches as tight and
throbbing
Describes headache location as behind
her forehead
Rates headache pain as a 3 or 4
Reports treating headaches with Tylenol
Reading and studying seem to cause
headaches
Asked about review of systems for eyes Reports occasional blurry vision
Reports worsening vision
Denies eye pain
Denies dry eyes
Reports last vision exam was in childhood
Does not use corrective lenses
Followed up on vision problems Describes blurry vision as "fuzzy letters"
Blurry vision occurs when reading for long
periods
Blurry vision occurs after 2+ hours of
reading
Reports that blurry vision and headaches
often coincide
Asked about review of systems for ears Denies general ear problems
Denies change in hearing
Denies ear pain
Denies ear discharge
Reports last hearing test was in childhood
Asked about review of systems for nose Denies change in sense of smell
Reports no nasal or sinus surgeries
Denies nosebleeds
Asked about review of systems for mouth Denies general mouth problems
and jaw
Denies change in sense of taste
Denies dry mouth
Denies history of oral surgery
Denies mouth pain
Denies mouth sores
Denies gum problems
Denies tongue problems
Denies jaw problems
Asked about review of systems for Denies current dental problems
dentation
Reports visit within the last 2 years
Reports regular visits in childhood
Reports a few cavities in childhood
Asked about review of systems for neck,
Denies history of recurrent strep throat
throat and glands
Denies lymph node problems
Denies history of general throat problems
Denies voice changes
Denies history of tonsil problems
Denies general neck pain
Family History
Asked about relevant family history Reports sister with hay fever
Denies family history of vision problems
Denies family history of sinus problems
Denies family history of ear or hearing
problems
Denies family history of mouth, throat, or
gland problems
Denies family history of headache or
migraine
Comments
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